Healthcare Provider Details

I. General information

NPI: 1417579871
Provider Name (Legal Business Name): MARY ELIZABETH WALSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2020
Last Update Date: 08/08/2020
Certification Date: 08/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 BROADWAY FL 8
NEW YORK NY
10019-1412
US

IV. Provider business mailing address

668 ROSSVILLE AVE
STATEN ISLAND NY
10309-1706
US

V. Phone/Fax

Practice location:
  • Phone: 212-664-9323
  • Fax:
Mailing address:
  • Phone: 347-996-0652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number025428
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: